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The Firm Services has the latest information regarding ICD-10 and its implementation. Written by Daria Bonner, CHCA, CCP, RMC | Monday, 23 May 2016 00:00 Given the added specificity inherent in ICD-10, it’s no surprise that medical necessity denials for physician practices and medical groups are expected to increase throughout 2016. In addition to greater levels of code granularity, three key industry drivers are expected to impact ICD-10 coding compliance among physician practices in the year ahead. First, payers will continue to refine coverage policies based on the new code set. Second, the ICD-10 grace period for physician practices comes to a close as of Oct. 1, 2016. And finally, almost 6,000 new ICD-10 codes will be added that same day as the partial code freeze concludes. These factors will impact all providers, but they will be especially notable within physician practices and medical groups. Practices are also predicted to struggle with reporting ICD-10-CM diagnosis codes that aren’t medically necessary as it pertains to supporting the corresponding CPT codes. Without proactive planning, the following three specialties may see an increase in medical necessity denials in the months ahead: Cardiology Pathology/Laboratory Radiology This article takes a closer look at these specialties to identify common medical necessity gaps in physician documentation and clinical coding. Left open, these gaps carry the potential to increase denials, audits, and revenue loss in 2016. Cardiology Concerns With 42 national coverage determinations (NCDs), cardiology is both a high-volume and a high-value service line. While CPT and E&M codes prevail in cardiology claims, the correct assignment of an ICD-10 code drives medical necessity decisions through NCDs. Some cardiology practices are already experiencing medical necessity denials related to the following: Unspecified codes Incomplete codes [...]

Insurers are dropping out of Obamacare. You have questions? We have answers at The Firm Services. It's been more than two years since the Affordable Care Act, which you probably know better as Obamacare, went into full effect for individual consumers, and in that time the new health law has enrolled about 12.7 million people. Note that this doesn't take into account the millions of Americans who've been able to get health insurance through the expansion of Medicaid and CHIP within their respective states. In total, 31 states chose to accept federal money and expand their Medicaid program to provide healthcare to low-income individuals and families. On the surface, Obamacare has led to a statistically meaningful reduction in the number of people who are uninsured. Gallup's most recent survey in the first quarter pegged the uninsured rate at 11%, which is down 90 basis points from the fourth quarter, and is 6.1% lower than Q4 2013, the quarter prior to the full implementation of Obamacare. The program has presumably opened the door for millions of lower-income Americans and those with pre-existing health conditions to get the medical care they need. But Obamacare has also opened the door to another set of problems that question its ongoing survival. An Obamacare exodus For instance, UnitedHealth Group (NYSE: UNH), the largest insurer in the U.S., recently announced that it would be vacating a majority of the 34 states it's currently operating in beginning in 2017. The reason? Higher member utilization rates and the ease with which consumers can change health plans are set to cause UnitedHealth to lose around $500 million on its Obamacare individual marketplace plans in 2016. Mind you, we're talking about the largest [...]

ICD-10 LET THE FIRM SERVICES BOOST YOU OVER THE OBSTACLES CARL NATALE MAY 17, 2016 - 08:04 PM for ICD 10 Watch Healthcare providers should be getting ready for an increase in claim denials. It was mentioned earlier this week that healthcare payers may be simply gathering ICD-10 data they can use identify problems later — like after Oct. 1. This data could drive denial decisions. Speaking of data. If healthcare payers are going to be using data to find problems in medical practices, shouldn't medical practices start looking at data to find those problems first? That's what Debi Primeau did in her For the Record analysis of eight potential denial targets: Sequencing: Review the ICD-10-CM guidelines to make sure right ICD-10 codes are chosen for the primary diagnosis. Aftercare: The Z codes designate specific instances of aftercare. But usually it is correct to use the injury ICD-10 code with the seventh character designating a subsequent encounter. Seventh character:Speaking of subsequent encounters. It doesn't mean what many healthcare professionals think it does when they're trying to be clever. Unspecified codes:Yes, they do exist. But will auditors start looking for them? Laterality: It's great that ICD-10 codes allow to differentiate between the left and right sides of the body. But sometimes one bilateral code is needed instead of two diagnosis codes to designate the left and right side as affected. Hip and knee replacements: Use ICD-10-PCS codes for removal and replacement. Missing codes: This may get some physician push back. But the guidelines require supporting diagnoses in some cases. Medical necessity: This is going to require keeping up with local coverage determination (LCD) and national coverage determination (NCD) updates. If ICD-10 denials haven't been a problem, that doesn't [...]

Richard Wolf, Gregory Korte and Jayne O'Donnell, USA TODAY 6:02 p.m. EDT May 12, 2016 WASHINGTON — Republicans won the first round Thursday in a separation of powers battle against President Obama that once again focuses on his most prized achievement: Obamacare. Federal district Judge Rosemary Collyer, a Republican appointee, ruled that the law did not provide for the funds insurers need to make health insurance policies under the program affordable. While the law provides for tax credits, she said, it does not authorize an appropriation for slashing deductibles and copayments. Without those reductions from insurers, many consumers could not afford to buy insurance. "Congress authorized reduced cost-sharing but did not appropriate monies for it,," Collyer said in her 38-page ruling. "Congress is the only source for such an appropriation, and no public money can be spent without one." Collyer blocked her own decision from taking effect while awaiting a likely appeal from the administration. Cost-sharing subsidies reduce consumers' insurance payments — an important feature of the Affordable Care Act, because deductibles are rising. Under the law, subsidies are available to people who earn between 100% and 400% of the federal poverty level, with extra assistance available for those up to 250%. For a family of four, that’s about $24,000 to $61,000. The Commonwealth Fund estimated up to 7 million people might have plans with cost-sharing reductions this year. The ruling does not represent as big a threat to the health care law as two previous conservative challenges swatted down by the Supreme Court in 2012 and 2015. The first would have gutted the law; the second would have eliminated tax credits in many states. “It’s a setback, and it’s a distraction … but a [...]

Credentialing? Let the experts at The Firm Services complete it for you. Provider credentialing and enrollment is an absolute necessity when running a successful physician practice. Becoming a provider with commercial and government insurance companies allows you to maintain steady patient referrals and cash flow which is the backbone of any successful practice. Avoiding these credentialing mistakes will ensure your credentialing and enrollment process moves along efficiently and effectively. Here are the top 4 commonly made mistakes. 1. Incomplete Information The most common mistake associated with credentialing is a lack of attention to detail. Application errors lead to delays and potentially denials. A typical credentialing application will ask for practice address, phone, fax, contact information, services provided, copies of your licensure, employment history, average patient profile and any records of past legal troubles regarding your medical practice. Omitting or making mistakes on any of this data can lead to delays in your provider credentialing, and it can sometimes be grounds for a denial. The solution? All your provider applications should go through a rigorous review process to certify accuracy before it is submitted to committee. Getting it right the first time means you'll get a new provider credentialed faster. 2. Lack of Follow-Up Many plans are backlogged with credentialing applications. Make every effort to confirm your application was received and where in the process it is. If something sounds like it does not make sense, question the response. We often hear “I have no record of the application” and when presented with evidence of receipt via a trackable transit confirmation, the answer changes to “Oh, it is on my desk." Make sure you understand the answer before you accept it. Follow-up at regular [...]